血透病人中心静脉狭窄的诊治研究

目的 探讨血透病人中心静脉狭窄的诊治经验。方法 回顾性分析上海交通大学医学院附属仁济医院2006年7月至2008年7月收治的13例中心静脉狭窄的血透病例临床资料。结果 有同侧中心静脉插管史病人占61.54%,表现为上肢肿胀、静脉高压,中心静脉双侧病变1例,单侧病变12例,锁骨下静脉、头臂静脉闭塞各2例,头臂静脉狭窄3例,锁骨下静脉狭窄5例。采用球囊扩张术、锁骨下静脉-对侧锁骨下静脉旁路术、血透通路关闭术治疗,症状缓解。结论 血透病人中心静脉狭窄的临床症状严重,并影响了血透通路的使用和寿命,静脉造影仍是首选诊断方法,而治疗的远期疗效尚待进一步探讨。     

中心静脉插管与直接动脉穿刺血透治疗比较

目的：观察中心静脉插管（CVC）和直接动脉穿刺（AP）的透析效率,可维持透析时间及并发症并进行比较。方法：50例血透病人,22例行CVC（双腔静脉导管）单针单泵透析;28例行AP透析,于透析前,透析后不同时间采血查肾功,电解质,HCO3^-浓度。结果：CVC及AP对BUN,血Ca^2 ,P^3-浓度的影响相似（P＞0．05）,而首次透析2h后血K^ ,HCK3^-浓度的变化似与其相应透析前浓度测定值的水平有关,Scr浓度变化（降低）,AP组大于CVC组（P＜0．05）,可能由于存在通路再循环的影响,CVC常见并发症为感染,细菌为表皮葡萄球菌,AP常见并发症仍为血肿或动脉瘤,结论：CVC与AP作为临时性血管通路的短期透析效率相似,但CVC有减少穿刺,保护血管的优点。     

经皮颈外静脉深部插管行血液透析25例体会

终末期肾衰竭行血液透析的初期 ,其他疾病暂行血液透析的患者 ,为了建立血管通路 ,常行深静脉插管 ,选择部位为 :颈内静脉、锁骨下静脉及股静脉。因选择上述部位进行穿刺插管各有优缺点 ,我们在工作中逐渐探索 ,开展经皮颈外静脉深部插管行血液透析 ,现将 1年内的资料进行总结分析。资料与方法1　病例选择　 (1)患者有易出血倾向 ,深静脉插管出血形成血肿危险性较大者 ;(2 )颈外静脉较充盈者 ;(3)深静脉穿刺困难或有禁忌者。2　静脉插管材料　ＡＲＲＯＷ双腔套管 ,型号ＣＳ -12 12 2 -Ｆ。3　穿刺方法　患者仰卧 ,肩部垫高 ,头低位。选取颈…     

中心静脉插管相关性感染因素分析及护理

目的对中心静脉插管相关性感染因素进行原困分析,并提出护理对策。方法对我科28例行48次中心静脉导管穿刺患者进行中心静脉导管尖培养结果进行回顾性分析。结果培养阳性5例,其中表皮葡萄球菌2例,肺炎克雷伯杆菌1例,鲍蔓不动杆菌1例,铅黄球菌1例,白假丝酵母菌1例,感染率10.3%(5/48)。结论留置导管时间过长,忽略插管部位的监测和护理,无菌操作不严格,高渗静脉液等是引起中心静脉导管相关感染的主要原因,加强基础性疾病的治疗及抗生素技术的应用等可减少中心静脉导管穿刺相关感染的发生。     

外周切割球囊治疗血液透析患者内瘘狭窄四例

血透患者内瘘狭窄是临床上较难处理的一个问题，而应用外周切割球囊（PCB）治疗内瘘狭窄经检索目前国内尚无报道。我院自2006年4月至9月，应用外周切割球囊对部分血透患者内瘘狭窄段进行扩张治疗，取得了良好的近期疗效和初步的临床经验，现报告如下。     

中心静脉插管相关性感染的治疗体会

随着中心静脉导管的广泛应用，插管相关性感染成了危重病人感染的一个常见类型，严重时可危及病人的生命。现将我院ICU2000年至2002年间出现的中心静脉插管相关性感染40例报告如下。     

股静脉穿刺插管200例总结

笔者于 1991年 1月～ 2 0 0 1年 12月对门诊及住院血透和血液灌流病人共进行股静脉穿刺插管 2 0 0例 ,除 2例误入股动脉 ,1例穿刺失败外 ,均获成功 ,成功率为 98.5 % ,血流量均能满足透析需要。资料与方法1　临床资料　男 14 1例 ,女 5 9例 ;年龄 4岁～ 81岁 ,平均 38.5岁。 197例选择右侧股静脉穿刺 ,3例选择左股静脉穿刺。急性肾衰竭和 /或急性中毒共 115例 ;慢性肾衰竭 85例 ,其中有可逆因素需做临时透析者 35例 ,内瘘未成熟需做紧急透析 5 0例。2　方法　以右侧股静脉穿刺为例[1] :常规消毒、铺巾、病人仰卧 ,右下肢外展、外旋 ,膝关节…     

球囊扩张治疗医源性输尿管狭窄12例分析

目的探讨球囊扩张治疗医源性输尿管狭窄的方法与疗效。方法回顾性分析2010年6月至2013年7月期间采用球囊扩张治疗12例医源性输尿管狭窄患者的临床资料。结果12例均成功行输尿管狭窄球囊扩张治疗。术后随访6～24个月,平均12个月,肾积水明显减轻8例;肾积水无明显变化3例;狭窄复发二次行球囊扩张后好转1例,术后患者复查CTU肾积水减轻。结论球囊扩张联合双J管内引流是治疗医源性输尿管狭窄的有效方法。只要选择合适的病例,其疗效可靠。与传统开放手术相比,创伤较小,更易于为患者接受。与其他内镜下狭窄扩张方法相比,效果确切,并发症较少。     

中心静脉导管相关性脓毒症分析

我们对实施经皮穿刺中心静脉插管术的病人进行临床观察 ,探讨经皮穿刺中心静脉插管术后感染因素及防治对策。1　材料与方法1998～ 2 0 0 0年在我院外科行经中心静脉导管 (ＣＶＣ)输液共 10 38例。选取有临床感染征象而无其它感染灶者 5 5例作为本研究对象。其中原发病为恶性肿瘤 31例 ,急性胰腺炎14例 ,胆道结石 5例 ,其它外科疾病 5例。按置管用途分为 :静脉营养 34例 ,术中监护及监测中心静脉压 6例 ,化疗 12例 ,普通输液 3例。中心静脉导管留置时间 4～ 43天 ,平均17 6天。以Ｓｅｌｄｉｎｇｅｒ法进行颈内或颈外静脉插管。本研究分中心静…     

血液透析患者中心静脉长期导管感染相关因素的分析

目的：分析本院血液透析中心静脉长期导管感染的发病率、相关因素。方法：回顾性调查分析47例中心静脉长期导管患者的原发病,导管留置时间,病原菌分布。结果：原发病为糖尿病肾病,贫血越严重,导管留置时间越长者,中心静脉长期导管感染发生率越高,差异均有统计学意义（P〈0.01）。结论：血液透析患者中心静脉长期导管留置时间超过2年是引起中心静脉导管相关感染的主要原因,感染菌种以革兰阳性菌为主。缩短留置时间可减少血液透析中心静脉长期导管相关感染的发生。     

Late symptomatic venous stenosis in three hemodialysis patients without previous central venous catheters

It is well known that catheters placed in the subclavian or internal jugular veins may develop stenosis in the vein in which the catheter lies. Because the arteriovenous fistula (AVF) relies on good venous outflow, patients with ipsilateral central venous stenosis are subject to the malfunctioning of AVF. Until now, no data were published on patients showing central vein stenosis (CVS) without a previous central venous catheter (CVC) or a pacemaker. In this article, we report on 3 hemodialysis patients manifesting CVS ipslateral to AVF. None of these patients previously had undergone CVC. The stenosis observed had characteristics and symptoms similar to those observed in stenoses consequent to CVC. We concluded that CVS also may occur in subclavian or axillary veins proximal to a working AVF in hemodialysis patients who have never had a CVC and in the absence of compressive phenomena.     

Evaluation of dilators for central venous catheterization using an experimental model

Purpose Skin incision before percutaneous central venous catheterization may cause serious hemorrhage and/or skin cicatrization. To minimize these adverse effects, we improved the shape of a dilator and coated it with lubricant to reduce insertion load.Methods We selected three types of dilators from different manufacturers. Each brand was widely available on the market in Japan. We redesigned one model with modified multitapering angles. Six types of dilators in total (three manufactured dilators, one manufactured dilator with lubricant, and the newly modified dilator +/– lubricant) were examined regarding load of insertion using pork muscle covered with porcine skin. Among these dilators, two manufactured dilators and the newly modified one with lubricant were also investigated regarding insertion load with or without skin incision.Results The minimum load of insertion was observed in the newly modified dilator with lubricant. The modified dilator attenuated the insertion load by up to 50% of the manufactured dilator, and the lubricant also reduced load by up to 16%. The insertion load of the modified dilator coated with lubricant was comparable to that of the manufactured dilators inserted with a 2-mm skin incision.Conclusion The lubricant-coated dilator with multitapering angles was associated with decreased insertion load and thus facilitated its insertion without skin incision.     

Clinical application of covered metal stents in treating central venous occlusion of different branches in hemodialysis patients

Objective To evaluate the efficacy of covered stent (CS) in the treatment of central venous occlusive disease (CVOD) of different branches in hemodialysis patients. Methods Twenty-five cases of CVOD in the First Affiliated Hospital of Sun Yat-sen University from Oct 2015 to June 2018 were enrolled. All patients underwent percutaneous transluminal angioplasty (PTA)+stent graft (PTS) successfully. The stent grafts of different diameters were implanted according to intraoperative angiography to measure the diameter of normal blood vessels around the diseased vessels. The operation was successful and the follow-up data was complete. According to the different branches of central venous lesions, the patients were divided into three groups: subclavian vein group, brachiocephalic vein group and superior vena cava group. The stent diameter, primary patency and assisted primary patency time were analyzed and compared in the three groups. Results The diameters of the subclavian vein group, the brachiocephalic vein group, and the superior vena cava group were (10.29±0.42) mm, (12.29±0.32) mm and 13.00 mm, respectively. There were significant differences in the diameters of the subclavian vein group, the superior vena cava group and the brachiocephalic vein group (both P＜0.05). As of the end of follow-up, the primary patency time of the subclavian vein group, the brachiocephalic vein group, and the superior vena cava group was (10.57±2.00) months, (19.40±3.28) months, and (32.75±3.28) months respectively. The primary patency time of the superior vena cava group was significantly longer than the other two groups (P＜0.05). There was no significant difference in the primary patency time between the subclavian vein group and the brachiocephalic vein group (P=0.072). The assisted primary patency time of the subclavian vein group, the brachiocephalic vein group and the superior vena cava group was (15.57±3.20) months, (25.14±2.39) months, (39.00±3.03) months. There was a statistically significant difference in the assisted primary patency time between the three groups (P＜0.05). Conclusions There are differences in vascular patency between postoperative vascular grafts of different diameters in different sites. The larger the diameter of the lumen stent, the longer the stent patency time is. It is important to protect the blood vessels with smaller diameters.     

Instructional design affects the efficacy of simulation-based training in central venous catheterization

Background

Simulation-based learning is a common educational tool in health care training and frequently involves instructional designs based on Experiential Learning Theory (ELT). However, little research explores the effectiveness and efficiency of different instructional design methodologies appropriate for simulations. The aim of this study was to compare 2 instructional design models, ELT and Guided Experiential Learning (GEL), to determine which is more effective for training the central venous catheterization procedure.

Methods

Using a quasi-experimental randomized block design, nurse anesthetists completed training under 1 of the 2 instructional design models. Performance was assessed using a checklist of central venous catheterization performance, pass rates, and critical action errors.

Results

Participants in the GEL condition performed significantly better than those in the ELT condition on the overall checklist score after controlling for individual practice time (F[1, 29] = 4.021, P = .027, Cohen's d = .71), had higher pass rates (P = .006, Cohen's d = 1.15), and had lower rates of failure due to critical action errors (P = .038, Cohen's d = .81).

Conclusions

The GEL model of instructional design is significantly more effective than ELT for simulation-based learning of the central venous catheterization procedure, yielding large differences in effect size.     

Verification of the position of a central venous catheter by intra-atrial ECG. When does this method fail?

The purpose of this study was to determine why intra-atrial ECG tracing for checking the position of a central venous catheter fails in certain patients. Three hundred and fifty prospective and consecutive patients scheduled for central venous catheterization using various puncture sites and techniques were investigated. The catheters were 20 cm in length. After its introduction, the catheter was connected to an Alphacard® (Sterimed, Saarbrücken) for the intra-atrial ECG tracing. The method failed in 29 patients, of whom nine had manifest myocardial pathology. In two patients the catheter looped, while in the remaining 18 the catheter proved to be too short. In these 18 patients, the cannulation was mainly performed via the external jugular vein and/or from the left side. Most of the patients were elderly males, and 11 of the 18 patients showed radiological signs of pulmonary emphysema. In such individuals it is advisable to use a catheter longer than 20 cm.     

Glomerulonephritis associated with chronic infection from long-term central venous catheterization

There have been few reports on immune complex-mediated glomerulonephritis associated with chronic infection from long-term central venous catheterization in adulthood. We report here on a 13-year-old boy with nephritis who exhibited glomerulonephritis that had been induced by the long-term use of central venous catheters, and its resolution after extraction of the central venous catheter. A diagnosis of glomerulonephritis associated with chronic infection caused by long-term central venous catheterization was made, based on the absence of clinical findings after removal of the catheter, hypocomplementemia, pathology findings resembling membranoproliferative glomerulonephritis, and detection of Staphylococcus epidermidis from culture of the removed catheter culture. For clinicians using long-term central venous access for parenteral feeding, rapid catheter exchange is necessary for patients with fever of unknown origin.     

Percutaneous central venous catheterization through the external jugular vein in children: improved success rate with body maneuvers and fluoroscopy assistance

Background/Purpose

Central venous catheterization is among the most common procedures performed by pediatric surgeons. Significant morbidity and even mortality can ensue from the widespread approach to the deep veins of the neck and femoral region. The external jugular vein (EJV) is a low-morbidity alternative for percutaneous catheterization in children, but it has yielded a low success rate in previous reports .The authors show an improved success rate with this option.

Methods

We performed an analysis of 33 patients' charts in which central venous catheterization using Seldinger technique through the EJV was attempted in 2005. Age, diagnosis, maneuvers used for success, fluoroscopy usefulness, and types of inserted catheters were evaluated.

Results

The procedure was successful in 26 (78.8%) patients without complications. Diagnosis was neoplasia in almost half of the patients (42%). In half of the successful cases, body maneuvers were used, namely, twisting the head of the patient to the side of the vein and stretching the ipsilateral arm and shoulder. All but one procedure were completed under fluoroscopic guidance. In 6 (23%) patients, a long-term catheter was inserted.

Conclusions

The EJV is an excellent option for central venous catheterization in children. The execution of simple maneuvers along with fluoroscopic assistance might allow for an improved success rate not only for short-term but also for long-term catheter insertion.     

中心静脉导管室医护一体急救管理模式的构建与实施

目的构建中心静脉导管室的急救管理模式,保障中心静脉置管过程的安全。方法成立中心静脉导管室急救小组,从健全各种急救制度、急救人员统一培训等方面构建一个全方位、多学科参与的“医护一体”急救管理模式。结果2012年1月至2013年10月共置管30674例次,置管过程中共进行61例次急救,抢救成功率100％,且患者转归良好。2013年置管并发症低于2012年。结论对医院中心静脉导管室实施“医护一体”急救管理模式提高了置管人员的风险防范能力,提升了护理专业水平,保障了患者安全。